Accessible Unlicensed Requires Authentication Published by De Gruyter October 12, 2020

Non-adherence to labor guidelines in cesarean sections done for failed induction and arrest of dilation

Christina M. Escobar, Amos Grünebaum, Eunice Y. Nam, Amber T. Olson, Yuzuru Anzai, Maria Teresa Benedetto-Anzai, Teresa Cheon, Alan Arslan and W. Spencer McClelland



In 2014, the American College of Obstetrics and Gynecology published guidelines for diagnosing failed induction of labor (FIOL) and arrest of dilation (AOD) to prevent cesarean delivery (CD). The objectives of this study were to determine the rate of adherence to these guidelines and to compare the association of guideline adherence with physician CD rates and obstetric/neonatal outcomes.


Retrospective cohort review of singleton primary cesarean deliveries for FIOL and AOD at a single academic institution from 2014 to 2016. Univariate and multivariate analyses were used to compare adherence to the guidelines with physician CD rates and obstetric/neonatal outcomes.


Of the 591 cesarean deliveries in the study, 263 were for failed induction, 328 for AOD and 79% (468/591) were not adherent to the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (ACOG/SMFM) guidelines. Of the failed inductions, 82% (215/263) and of the AODs 77% (253/328) were not adherent. There was no difference between adherent and non-adherent CDs with regard to maternal characteristics, or obstetric/neonatal outcomes. Duration of oxytocin use after rupture of membranes, dilation at time of CD, and birth weight were statistically higher in adherent CDs. On multivariate linear regression, physician CD rates were inversely correlated with adherence to ACOG/SMFM guidelines (p<0.0001), gestational age (p=0.007), and parity (p=0.003).


Our study shows that physician non-compliance with ACOG guidelines was high. Adherence to these guidelines was associated with lower physician CD rates, without an increase in obstetric or neonatal complications.

Corresponding author: Christina M. Escobar, MD, Fellow, Female Pelvic Medicine and Reconstructive Surgery, Obstetrics and Gynecology, New York University Langone Medical Center, 462 First Avenue, New York, NY10016, USA, Phone: +1 813 766 4022, E-mail:

  1. Research funding: None declared.

  2. Author contributions: WSM, YA, MTB and TC designed the study. AO and EN built the database, WSM and CE analyzed the database and reviewed each CD and applied guidelines. YA settled any disputes. AA performed statistics. CE, WSM, YA, MTB, TC and AG all wrote and edited the manuscript. All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Authors state no conflict of interest.

  4. Informed consent: Informed consent was obtained from all individuals included in this study.

  5. Ethical approval: Ethics approval and consent to participate: The research related to human use has been complied with all the relevant national regulations, institutional policies and in accordance the tenets of the Helsinki Declaration, and this study was approved by the Institutional Review Board at our study institution (18-01964).

  6. Location of study: Obstetrics and Gynecology, New York University, New York, NY.

  7. Availability of data: The dataset from this article is not available due to the fact it contains protected health information.

  8. Findings presented at: Society of Maternal Fetal Medicine 2018, Poster presentation, Abstract #832, Dallas, TX, January 29th–February 3rd, 2018.

Appendix 1

Patient characteristics
Gestational ageDetermined based on the last menstrual period, confirmed with or corrected by first- or early second-trimester ultrasonography
Body mass index (BMI)
Medical and obstetric co-morbidities
Prior cesarean delivery
Chronic hypertensionElevated blood pressure (BP) ≥140/90 with first elevation at less than 20 weeks of gestation
Gestational hypertensionElevated BP as above with first elevation at 20 weeks of gestation or greater
PreeclampsiaElevated BP as above with proteinuria of 1+ or more on urinalysis or ≥300 mg over 24 h
Pre-gestational diabetesDiabetes diagnosed before pregnancy or before 20 weeks
Gestational diabetesDiabetes diagnosed during pregnancy based on an abnormal 3 h glucose tolerance test
OligohydramniosAmniotic fluid index less than 5 cm
Intrauterine growth restrictionEstimated fetal weight less than the 10th percentile
Other maternal comorbiditiesCancer, rheumatologic disorders, and epilepsy
Labor characteristics
Bishop score at presentation
Induction of laborCategorized based on the provider’s documentation in the admission note and confirmed by review of the history, initial cervical exam, and tocodynamometer findings
Induction methodsProstaglandin, cervical balloon, oxytocin
Augmentation methods
Duration of oxytocin administration
Duration of rupture of membranes
Use of intrauterine pressure catheter (IUPC)
Labor complicationsMeconium, chorioamnionitis or any hypertensive disorder that developed during labor
Delivery characteristics
Obstetrician at time of delivery
Indication for cesarean deliveryBased off indication listed in the operative report
Date and time of cesarean delivery
Cervical exam at time of delivery
Fetal position at time of deliveryDefined as favorable or unfavorable, with favorable positions being any occiput anterior position
Category of tracing at time of deliveryBased off documented category of tracing by physician at time of delivery

If no category of tracing was documented, or if there was a discrepancy within the documentation at time of delivery, the strip was reviewed by two different reviewers (CE and SM)

If there was a disagreement between these two reviewers, a third reviewer (YA) made the final determination
Cesarean complicationsTransfusions, endometritis, wound complications and neonatal injuries
Estimated blood loss
Neonate dispositionDefined as admission to either the neonatal ICU or regular nursery
Birth weight
APGAR scoresAt 1 min and 5 min


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Received: 2020-07-19
Accepted: 2020-08-04
Published Online: 2020-10-12
Published in Print: 2021-01-26

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